2

Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention

Illness Compensation Act jational Institute for Occupational Safety and Health
° og-15-12P01:53 Rov P ty

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form A Page 1 of 2

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
_ this number will not result in the denial of any right,-benefit, or privilege to which you may be entitled.

Instructions on Completing this Form:

You should use this petition form only if NIOSH has reported to you in writing that it cannot complete the
dose reconstruction needed for your cancer claim.

All other petitioners should use Petition Form B to submit a petition to NIOSH.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.

NIOSH Claim Information — Complete as much information as you can in Section A.

A.1 NIOSH Tracking Number (indicated on all NIOSH correspondence):

A.2___ Print Name of Energy Employee for whom this claim was filed:

Mr./Mrs./Ms. First Name Middle Initial Last Name /

A3 Social Security Number of Energy Employee for whom this claim was filed:

Signature of Person Submitting this Petition — Complete Section B.

Print and sign your name below to indicate that you are petitioning for HHS to consider adding a class
of employees to the Special Exposure Cohort that would include the employee indicated by the
tracking number or name under entry 1 above.

Det rae an alae Qian ane mame halaur a A

First Name

Middle initial Last Name* rirst Name wiggle intial Last Name,

Please send this form to NIOSH at the address below.

Once NIOSH receives this form, the U.S. Department of Health and Human Services will consider adding a
class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to inform you of
the progress of your petition.

Send this form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

Name or Social Security Number of First Petitioner:


.| Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 09/20/2013
Special Exposure Cohort Petition — Form A Page 2 of 2

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 3 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.
Persons are not required to respond to the information collected on this form unless it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following: ‘

The Energy Employees Occupational IlIness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed
below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal
agencies, other government or private entities and to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner:


OFFICIAL BUSINESS
Penalty for Private Use $300

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NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY & HEALTH
ROBERT A TAFT LABORATORIES

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CINCINNATI,OH 45226-9987

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